Provider Demographics
NPI:1215958863
Name:FAYETTE COUNTY
Entity type:Organization
Organization Name:FAYETTE COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:P
Authorized Official - Last Name:VANDEVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-968-8991
Mailing Address - Street 1:PO BOX 9150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-9150
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-8642
Practice Address - Street 1:1721 VON MINDEN RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-2400
Practice Address - Country:US
Practice Address - Phone:979-968-8991
Practice Address - Fax:979-968-9488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75001341600000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
590900060OtherRAILROAD MEDICARE
TX086425801Medicaid
TX503683OtherBC/BS OF TEXAS
TX=========OtherTRICARE
590900060OtherRAILROAD MEDICARE